Global Polio Eradication Requires Counteracting Anti-UN, Anti-vaccination Forces

Commentary by Nellie Bristol

Published April 23, 2024

Enduring bipartisan U.S. support for the Global Polio Eradication Initiative (GPEI) has carried the program within striking distance of its ultimate goal. But as the effort strives to eliminate the paralyzing disease in the world's most challenging geographies, an undercurrent of anti-internationalist and anti-vaccination sentiment could threaten progress, allowing the virus to thrive once again. To avoid this potent threat to the world's children, the U.S. government should maintain its strong partnership with the GPEI, including the World Health Organization (WHO) and UNICEF, and actively counteract mis- and disinformation related to lifesaving vaccinations.

The successful conclusion of the GPEI will require patience and realism, but continued incremental progress toward the endgame is within reach. As proven by the Covid-19 pandemic, outbreaks anywhere threaten lives and economies everywhere. Polio eradication is a matter of U.S. national interest, as well as a global health security priority, and needs to be understood as such. Success relies on sustained U.S. leadership and investment, including an active commitment to continued bipartisan support in Congress and future administrations despite the toxic polarization that surrounds much discussion of epidemic control.

The global effort to eradicate polio has had unprecedented staying power and many successes. Over its 35-year history, it has reduced polio cases by more than 99 percent and eliminated two of the disease's three naturally occurring strains. It has saved 20 million people from paralytic disease and disability and averted more than 900,000 polio-related deaths. Investments in polio infrastructure have bolstered other health campaigns and provided critical emergency response resources, including during the peak of the Covid-19 pandemic.

Working in the most fragile and under-resourced areas in the world, the GPEI has grappled with weak health systems, hostile terrain, extremist condemnations, attacks on vaccinators, Covid-19 health service disruptions, and deeply ingrained mistrust of outside authorities. It has weathered operational glitches including cash crunches, vaccine shortages, and programmatic errors. As a result of these and other barriers, the initiative's accomplishments have been hard won, and the challenging goal of global eradication remains elusive. The GPEI's current strategy aims to stop polio transmission everywhere by the end of 2026, but that goal is now considered unreachable as cases are already cropping up this year in Afghanistan and Pakistan, the only remaining endemic countries. In addition, other potential hazards loom as countries around the world become more insular and mistrust of science-including vaccinations-endures.

The massive reduction in naturally occurring global polio cases-from an estimated 350,000 when the program began in 1988 to 12 confined to Afghanistan and Pakistan last year-was instigated and sustained through major contributions by U.S. institutions. The effort was spearheaded by the Chicago-based Rotary International, which has been a tireless advocate and fundraiser around the world since the program's establishment. Rotary is one of the GPEI's six core partners, along with the U.S. Centers for Disease Control and Prevention (CDC) and the Bill & Melinda Gates Foundation. Multilateral partners include the WHO; Gavi, the Vaccine Alliance; and UNICEF. The U.S. government has been one of the program's top financial supporters at more than $4.7 billion since 1988, second only to the Gates Foundation's $5 billion. Rotary International comes in third at $2.7 billion.

In addition to averting millions of polio cases around the world, leadership by U.S. institutions and their partners-including the WHO and UNICEF-has created substantial added benefits:

• Disease detection and response capabilities have aided low-resource countries in a variety of health emergencies, ranging from earthquakes and floods to Covid-19.
• Enhanced disease surveillance systems bolster the world's ability to detect and respond to potential pandemics.
• An innovative accountability mechanism-the Independent Monitoring Board (IMB)-has provided regular, detailed analyses of programmatic operations at the country, regional, and global level and solid recommendations for improvement over a 13-year period and is a model for similar oversight functions.
• Development of an enduring public-private partnership among the GPEI's core global partners has sustained the acute focus required to immunize every child in the world against the disease.

But, as it has throughout much of its history, the program faces daunting challenges. While it has engineered significant reductions in polio transmission in the remaining endemic countries, operational and political barriers continue to thwart the widespread immunization required to eradicate the disease. While the Taliban has loosened its restrictions on the program's efforts in Afghanistan, one of the most effective immunization methods-house-to-house visits-remains off the table in the south as the country also grapples with fragile health services and an ongoing humanitarian crisis. Despite hard-won progress in Pakistan, insecurity and a challenging political environment have left limited but significant pockets of the country's children missed or under-vaccinated. These continuing challenges have resulted in Pakistan and Afghanistan already reporting two polio cases apiece this year.

On top of obstacles to eradication of wild poliovirus, the program is facing outbreaks of variant poliovirus that have occurred in multiple countries over the last four years. Variant polioviruses occur if the weakened strain of the virus contained in the oral polio vaccine circulates in areas of low immunization. Over time, the virus can mutate in under-immunized communities, sometimes reverting to an infectious form. Fueled by changes in vaccine strategy in 2016, vaccine shortages, and a halt in immunization campaigns during the height of the Covid-19 pandemic, more than 3,000 variant polio cases were recorded between 2019 and 2023. GPEI's strategy to stop the spread of these variant viruses has restricted them to just a few high-risk geographies suffering prolonged humanitarian crises, conflict, and instability: the Democratic Republic of the Congo, northwestern Nigeria, south central Somalia, and northern Yemen. While the number of variant cases decreased from 878 in 2022 to 523 in 2023, these outbreaks are still a major challenge and clearly demonstrate the type of resurgence possible without continued focus and support.

The GPEI's most recent strategy, covering 2022-2026, set goals to permanently interrupt poliovirus transmission in the two remaining endemic countries and stop transmission and outbreaks of circulating variant poliovirus. The IMB in its September 2023 mid-term evaluation of the strategy judged the program to be off track on both goals. The GPEI is pursuing several strategies to increase momentum, including the following:

• Wider distribution of a new vaccine, the novel oral polio vaccine, which has the ease of administration and specific immunizing properties considered critical for successful eradication but is 80 percent less likely to seed variant polio outbreaks
• Implementation of new disease detection technologies that would reduce the amount of time and money required to confirm cases of polio and facilitate faster responses
• Working closely with provincial officials in Pakistan and Afghanistan to ensure program access to unvaccinated children and increase the number of campaigns in those countries
• Heightened efforts to integrate polio vaccination with other immunization programs and basic health services

The initiative is also preparing a strategy addendum, adjusted timelines for achieving the strategic goals, and a related multiyear budget, which will be available in the second half of 2024.

In addition to the contributions of the broader global community, including national governments and the G7, these efforts depend on continued strong, bipartisan support from the United States. Despite an increasingly polarized political landscape, polio eradication is a global health issue on which policymakers from both sides of the aisle have found a common cause. The United States funds polio eradication largely through the CDC and the U.S. Agency for International Development (USAID), whose budgets for the work have grown steadily. Annual appropriations letters penned by Representative Joe Wilson (R-SC) and Representative Steve Cohen (D-TN), as well as Senator Jack Reed (D-RI) and Senator Roger Wicker (R-MS), aided in securing $265 million for the program in FY 2024. The lawmakers are now leading efforts for a larger infusion of funding for FY 2025, including $276 million for the CDC and $165 million for USAID. Senate Minority Leader Mitch McConnell (R-KY), a polio survivor himself, is an ally and is expected to continue to provide support after he steps down from his leadership position in November. U.S. contributions to Gavi, which is beginning a replenishment cycle this summer, help support continued rollout of inactivated poliovirus vaccine (IPV) to low-income countries including a hexavalent vaccine that contains an IPV component.

On the global stage, U.S. Department of Health and Human Services assistant secretary for global affairs Loyce Pace confirmed the U.S. government's strong support for polio eradication in a January statement at the WHO's Executive Board meeting, in which she called for halting wild poliovirus by the end of 2024, closing surveillance gaps, engaging with communities to gain trust, and increasing activities to strengthen routine immunization and provide maternal and child health education and vitamin A supplementation.

But while polio eradication itself has solid bipartisan support, other factors could threaten the program. These include a small but vocal anti-WHO contingent led by presumptive Republican presidential candidate Donald Trump, who as president halted U.S. funding to the global health organization. The action was reversed by President Biden, but some lawmakers remain dissatisfied with the WHO and have recently penned provisions to zero out its U.S. support, a position that would only be strengthened if Trump is reelected. The United States is a top financial supporter of the WHO, which is one of the essential coordinating bodies for the polio eradication effort and amplifies many other U.S. global health priorities and investments. Without the WHO's expertise and global reach, which is especially critical in parts of the world hostile to U.S. intervention, polio eradication could not be achieved. Research indicates that without a continued focus on eradication, polio cases could increase to 150,000 to 200,000 cases per year within a 10-year period.

Anti-vaccination efforts in the United States and elsewhere could also have troubling and wide-ranging impacts if allowed to take further hold. A recent rise in measles cases over the last few years in the United States, including 101 cases by mid-April 2024, is attributed to vaccine mis- and disinformation. And while polio is controlled in the United States through an inactivated vaccine that cannot revert to an infectious state, the virus was detected in wastewater in New York in 2022 and a positive case was confirmed in a traveler who returned to the United States after traveling abroad.

Fiscal scarcity is another concern. While the GPEI has attracted support from regional partners such as Saudi Arabia, Iran, Qatar, and the United Arab Emirates, one of its stalwart donors, the United Kingdom, has reduced its support as part of general decreases in international aid. GPEI documents indicate the program is facing a $1.2 billion funding gap for the remainder of the current strategy, which will hinder its ability to conduct the wider range of campaigns it was hoping for.

The global effort to eradicate polio has saved thousands of lives and produced a range of achievements, including elimination of polio strains, access to health interventions in low-income countries, and enhanced disease surveillance and response that help protect U.S. citizens against outbreaks of polio and other infectious diseases. U.S. government support for the program has been critical to all those achievements and is essential for eradication to succeed. Patience, realism, and grit remain essential to achieving success. Education of younger and newer members of Congress on the history of polio in the United States, how the eradication initiative has strengthened global health security, the critical and distinct roles played by key bilateral and multilateral agencies leading the effort, and the value of immunization overall are critical to preserving the unique and long-standing bipartisan support enjoyed by the program and ensuring the U.S. government continues to capitalize on the program's recent momentum.

Nellie Bristol is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

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